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Medical AssistingReview
Passing the CMA, RMA, and CCMA Exams
FifthEdition
© 2015 McGraw-Hill Education. All rights reserved..
Chapter 10
Appointments, Scheduling, Medical Records, Filing, Policies,
and Procedures
© 2015 McGraw-Hill Education. All rights reserved.
Learning Outcomes
• 10.1 Recall the different types of appointments and scheduling methods used in the medical office.
• 10.2 Demonstrate proper filing methods and the correct techniques for the handling of medical records.
• 10.3 Describe the importance of the policy and procedures manual.
10-2
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10-3 Appointments and Schedules
• Appointment book
• Legal record
• Types of appointments– New patient– Follow-up– Admissions– Laboratory tests– Surgery
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Appointments and Schedules
– Physician referrals– Salespersons, including pharmaceutical sales
representatives– Returning patients– Specialists– Buffer time
10-4
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10-5 Appointments and Schedules
• Abbreviations
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10-6 Appointments and Schedules• Scheduling process
– Office hours– Matrix– Scheduling guidelines– Considerations– Appointment cards– Phone– Special problems– Cancellations– Rescheduling
© 2015 McGraw-Hill Education. All rights reserved.
10-7 Appointments and Schedules
• Types of scheduling systems– Open hours– Time-specified scheduling– Double booking– Wave scheduling– Modified wave scheduling– Cluster scheduling
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10-8 Appointments and Schedules
– Advance scheduling– Grouping– Exceptions– Streaming– Computerized scheduling– Online scheduling
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10-9 Medical Records and Filing
• Reasons for medical records– Good medical records provide continuity– Supply statistical information– Used in lawsuits to protect patients– For evaluating quality of care in facilities– To facilitate reimbursements
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10-10 Medical Records and Filing
STANDARD INFORMATION IN MEDICAL RECORDS– Patient registration form– Patient medical history– Physical exam results– Results of lab tests– Copies and notes for prescriptions– Diagnosis and treatment plan– Patient progress reports and communication with patient– Informed consent forms– Discharge summary– Correspondence with and about patients
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10-11 Medical Records and Filing
Six Cs of charting
– Client’s words – Clarity– Completeness– Conciseness– Chronological order– Confidentiality
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10-12 Medical Records and Filing
Items to exclude from patient’s records
– Reports from consulting physicians – Financial information– Transferred records– Prejudicial, personal, or flippant comments
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10-13 Medical Records and Filing
Records management– Saving space– Reducing filing equipment expenditures– Preventing unnecessary record creation – Retrieving information faster– Reducing misfiles– Complying with legal safeguards– Saving the physician’s and patient’s time
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10-14 Medical Records and Filing
• SOAP– Subjective data– Objective data– Assessment– Plan
• POMR– Problem-oriented medical records
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10-15 Medical Records and Filing
• Medical transcription– Ensure accurate transcription
• Dictation– Ask for clarification
• Confidentiality
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10-16 Medical Records and Filing
Filing systems– Alphabetical– Alphanumeric– Subject filing– Chronological filing– Numerical filing– Color-coding – Computer records– Tickler file
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10-17 Medical Records and Filing
Filing procedures– Conditioning
– Releasing
– Indexing and coding
– Sorting
– Storing and filing
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Medical Records and Filing
• Active files
• Inactive files
• Closed files
• Transfer
• Retention period
• Identical names
• Business and organization records
• Misplaced files
10-18
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10-19 Medical Records and Filing
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10-20 Medical Records and Filing
• Filing equipment– File shelves– File cabinets– Movable file units– Filing supplies
• File folders• Identification labels• Guides and captions• Out guide
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10-21 Policies and Procedures
• Policies and procedures manual– Policies
• Office purposes, objectives, and goals• Rules and regulations• Job descriptions and duties• Office hours• Dress code• Insurance and other benefits• Vacation, sick leave, and other time away from the
office
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10-22 Policies and Procedures
• Performance evaluations and salary• Maintenance of equipment and supplies• Mailings• Bookkeeping• Scheduling appointments• Maintaining patient records• Health and safety guidelines• Organizational chart
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10-23 Policies and Procedures
• Procedures– Developing a Manual
• Develop an outline• Sources for development
– Journals– Product literature– Textbooks– Standards publications
• Manual format – many offices prefer a loose-leaf binder
